MRD Status May Help Personalize Myeloma Treatment

Minimal residual disease status may help personalize myeloma treatment.

The landscape of multiple myeloma is changing, which is now bringing in ways to help determine survival outcomes and a future treatment personalization, an expert told CURE®.

A study from the Journal of Clinical Oncology showed that identifying survival outcomes through minimal residual disease (MRD) was particularly helpful in determining treatment de-escalation (lessening the amount of treatment) and escalation (increasing the amount of treatment). Of note, knowing MRD status at one year after receiving an autologous hematopoietic cell transplantation with maintenance Revlimid (lenalidomide) boosted survival, researchers stated.

According to the National Cancer Institute, MRD is when patients have a very small amount of cancer cells during or after treatment. It also helps doctors detect cancer cells via tests or instruments, study author Dr. Marcelo Pasquini explained during an interview with CURE®.

Pasquini is a professor in the department of medicine at the Medical College of Wisconsin in Milwaukee.

“One example is to say that the evidence of minimal residual disease does not mean that the patient is sick,” Pasquini said. “But it means that really advanced methods [are needed] to detect very small amounts of cancer cells. Sometimes the presence of those cells may predict that the cancer will come back or come back in an earlier time point.”

Findings from this study are important for patients because there are “new techniques” to identify treatment decisions, said Pasquini. These techniques used include flow cytometry (lab test to test characteristics of cells) and next-generation sequencing (technology used for DNA and RNA sequencing and mutation detection).

Doing these tests helps determine the likelihood of the cancer returning, Pasquini explained.

“When I do this for patients in the clinic, I say, ‘Let’s see the depth of response because just like any test, we want to tell the patient what the probability that the cancer will come back is,” he said.

If the test returns negative, Pasquini said that it’s “very reassuring.” But if the test is positive, more active monitoring is the needed. As of now, he noted that the field still has to understand how to utilize these MRD tests as ways to help with treatment decision-making.

MRD and Treatment Decisions for Multiple Myeloma

Learning how to best utilize MRD status for treatment decision making may also help with understanding how much treatment patients should receive, Pasquini said. This approach could ultimately lead to “personalization of therapy,” he added.

“For example, I try to deescalate therapy if [patients] achieve and persist with very good disease control, meaning they had an excellent response,” he said. “Perhaps the decision is to deescalate therapy, so then patients aren’t exposed to drugs, and they don't get toxicity and side effects from those medications.”

Similarly, Pasquini noted that if patients remain MRD positive, meaning there is residual disease, then escalating treatment may be the best decision.

He emphasized that making informed decisions are important because “even though [therapies] are available, they can cause side effects and patients also [face] financial side effects.”

READ MORE: Combination Maintenance Therapy After Stem Cell Transplant May Prolong Survival in Multiple Myeloma

The Importance of Maintenance Therapy in Multiple Myeloma

Because multiple myeloma is currently an uncurable condition, Pasquini said, maintenance therapy is important. However, he noted that maintenance therapy is typically given after patients achieve and maintain a certain response to treatment.

Maintenance therapies like Revlimid prevent patients’ disease statuses from worsening, Pasquini explained. He also noted that previous trials have determined that Revlimid is less toxic and provided patients with overall survival (time from treatment until death of any cause) and progression-free survival (time from treatment until disease worsening or death) benefits.

“I'm seeing in the community that physicians are shifting the decision to use more of an intensified maintenance,” Pasquini said. “So I think maintenance is here to stay. The main question is, are there patients that we can deescalate? And I think these trials are going to be answered that in the future.”

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